Tuberculosis in Pregnancy

Munira Khan

AWACC 7th September 2017

Overview of Session

• Background

• Maternal mortality and the Saving Mothers Report

• Mortality in eThekwini with case studies

Overview

• TB epidemic in women

• Epidemiology of TB in pregnant women

• Maternal, perinatal and neonatal outcomes

Background (1) • Global TB report (2016):

– Estimated 10.4 million incident cases (range: 8.7-12.2 million)• 34% women*, 10% children*

– Gap between notifications and estimated incidence

* KEY populations and under estimated

Background (2)• Concerns specific to women:

– Exact incidence in pregnancy not known– Exact incidence of DRTB/ DSTB (pregnancy)– Impact on obstetric, perinatal and neonatal

outcomes inconsistently documented

• Disaggregate data for children

EPIDEMIOLOGY IN PREGNANT WOMEN

Sugarman The Lancet Global Health 2014

IMPORTANT CONSIDERATIONS

TB-HIV co infection in pregnancy• Unusual presentation

• Synergism:

– CMI with HIV increased with TB

– TB accelerates HIV progression

• TB and HIV independent risk factors for maternal deaths

Transmission from mother to child

• Transplacental through umbilical veins to fetal liver and lungs

• Aspirate or swallowing infected amniotic fluid in utero or intra partum

• Contact post delivery

MATERNAL, PERINATAL AND NEONATAL OUTCOMES

1. Antenatal TB

• 0.1% to 0.6% increase in TB case load (PTB*/ EPTB)• Diagnosis based on microscopy/ culture, CXR and

histology• Last 3 mths of pregnancy• 72% HIV infected • TB prevalence 10 fold higher in co infected women

Pillay T SAMJ 2000

Maternal

2. Maternal morbidity• PTL

• Higher risk of obstetric complications (PROM, recurrent abortions)

• EPTB (pleural effusions, abdominal and TBM common) required hospitalisation for longer periods

Figueroa-Damian 1998, Jana NEJM 1999

Maternal

Maternal and Neonatal TB• Initial report in neonatal TB in SA:

– 11 culture confirmed of 77 neonates over 1 year:• Gastric aspirates• 6 classified as congenital TB• Progressive pneumonia and fever

– Maternal history (n=11):• 6 of 11 HIV co infected• 6 mothers had active TB/ history of TB• 3 peripartum TB

– 1 neonatal (3mths) and 2 maternal deathsAdhikari M IJTLD 1997

Maternal

3. Maternal Mortality

• Zambia

• SA (2)

• MozambiqueAhmed IJTLD 1999, Menendez PLoSMed 2008, Black Obstet Gynecol 2009, Khan AIDS 2001

Maternal

4. Perinatal and neonatal outcomesAE higher if maternal TB advanced, diagnosed late in pregnancy,

non compliant

• Prematurity • LBW• SGA• Perinatal death rate 6.4 fold and 3.1 fold higher in TB infected

mothers• LBW and low Apgars: maternal EPTB

Neonatal

5. Congenital TB (1)• Rare or impression• DSTB and DRTB• Median age of presentation: 24 days (1-84)• Management dilemmas:

– BCG– Diagnostic challenge– Differential diagnoses– Prophylaxis– Breastfeeding

Neonatal

Pillay T Lancet Infectious Dis 2004

Non specific

Neonatal

POSTPARTUM TB

TB in post partum period• India 2002- 2005:

– 715 co infected women followed for 1 year post delivery– 24 developed TB (incidence 5 cases/ 100 p yrs)

• 3 maternal deaths, 2 infants developed TB and 4 infant deaths

– Predictors of maternal TB:• Baseline CD4<200, VL > 50 000 copies/ ml, (+) TST

Gupta A CID 2007

Maternal

Maternal

DRTB IN PREGNANCY, NEONATES AND CHILDREN

MDR in pregnancy/ post partum (1)

• Limited

• Case series or case reports

• Approximately 73 published (English)

• MTB and one M Bovis

• Largest cohort 38 (Peru) over 10 years

• Acceptable foetal outcomes in several small studies